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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page-L,f <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT V3 5.CHANGE OF INF0�2hfA ION �FYY� ❑ 7TERMANENTLY CLOSED SITE <br /> (Check one item only) ('4.AMENDED PERMIT specify change local use'Ionly L SS cy❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE O-onLLf 40° <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACILITY NAME or DBA-Doing Business As) 3 FACILITYID4 <br /> TrVk_Qi 1�i� l l0`1I <br /> EAREST CROSSTREET 401 FACILITY OWNER TYPE Ll 4.LOCAL AGENCY/DISTRICT* <br /> el.CORPORATION [15.COUNTY AGENCY* <br /> BUSFNES,V U 1.GAS STATION Lj 3,FARM Lj 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR Q6. OTHER w; ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS F Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE1 trustlands? operates the UST(This is the contact person for the tank records.) <br /> VA 404 ❑ Yes G3No aos 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILNG OR STREET ADDRESS 409 <br /> 3-g-00 yhl� Eli <br /> CITY 410 S 411 ZIP CODE 412 <br /> t f� lQ�F <br /> PROPERTY OWNER TYPE .CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNT)d AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> NKOWNER NAME V� �� . f� ala LtZL.f� 415 <br /> MAILING OR STREET ADDRESS �1`"1,`1,/� als <br /> P. "1 0131 <br /> VITY 417 STATE 418 ZIP CODE 41V9 DE 419 <br /> OLT __VX IVA7 no <br /> TANK OWNER TYPE L CORPORATION LJ2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 420 <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if quesfions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER 99. <br /> ❑3.INSURANCE [36.EXEMPTION [:]9.STATE FUND&CD OTHER: ,4zz <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chack one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER )6 3.TANK O WNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is tme and accurate m the best of my knowledge. <br /> GNATURE OF AP (CANT _ (' DATE 424 PHONE 4u <br /> '�J k �13-y 4SC7D <br /> NAME OF AP CANT(print) 420E OF APPLICANT 427 <br /> Ccs ev - VeV S <br /> STATE U917 FACILITY NUMBER(For local use only) 428 1998 UPGRA DE CERTIFICATE NUMBER(For l useonly) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />